Integrated Care and Support Pioneers Programme Building ...€¦ · Building Collaborative Teams A...

Building Collaborative TeamsA workshop guide for service managers and facilitatorsBringing teams together to deliver joined up care for people who use care and support services

Integrated Care and Support Pioneers Programme

2 Building Collaborative Teams© Copyright 2014 NHS Improving Quality. All rights reserved.

Contents

1. Introduction 32. Important factors and pre-workshop planning 93. Gathering patient experience 134. Workshops 225. Introduction to the workshop 256. Patient and user experience 327. Joint values and vision 358. Effective working relationships 439. Understanding roles 5110. Challenges to the perfect day 5511. What happens next? 6112. Appendices 6313. Literature and links 6814. Acknowledgments 71

In this guide we use the word service user or patient for consistency. Please feel free to use the most appropriate term for you.


1. Introduction‘There is a lack of common definitions of concepts underlying integrated care. As a consequence, a plethora of terms have been used, including 'integrated care','coordinated care', 'collaborative care' and many others. Thus, integration inhealthcare is not likely to follow a single path and variations will be inevitable.’National Evaluation of the Department of Health’s Integrated Care Pilots – March 2012


1. IntroductionA collaborative approach can improve communication, save time, reduce duplication of effort, improve workingrelationships and provide a better experience for people who use health and social care services.

This publication is designed as a ‘getting started’ guide for managers who are bringing different teams together. It’sintended to be used at the beginning, when one or more teams plan to work in a more integrated way. It contains toolsand exercises to help team members better understand each other’s role, attitude and values. It will help you to create ajoint action plan for working together, which will be co-produced during a series of workshops.

This guide is only a first step. As we capture learning from across the country, we hope to work with partners and localsites to produce further guides with more detailed information and best practice, drawn from areas where integratedteams are already working together well.

If you would like to be involved in developing the next guide to collaborative working, please get in touch by sending an email to [email protected]. ICASE is the shared online learning community for integrated care andsupport; visit it here: www.icase.org.uk

1. Intro

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Improving the integration of care across teams

We are all aware that when someone has a great experience when using health or social care services this is often the result ofhow different teams work together. By integrating the efforts of diverse teams you can often provide better care and a betterexperience for patients, carers and staff.

‘Integrated care and support... is the means to the end ofachieving high quality, compassionate care resulting inbetter health and wellbeing and a better experience forpatients and service users, their carers and families.’Our Shared Commitment, May 2013

1. Intro

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Purpose of this guide

This guide is designed to help bring together either two or more teams or an already integrated team composed of variousdisciplines, to explore opportunities to improve care by joint working on an action plan.

Who this guide is for?

This guide is written for the service managers or facilitators responsible for bringing together teams.

What does the guide do?

This guide:1. Identifies a number of important factors to be in place before frontline teams work together on an action plan.2. Provides a method for obtaining patient experience feedback.3. Describes ways that teams can consider and improve the effectiveness of their working relationships.4. Ensures teams understand each other’s roles more comprehensively.5. Provides facilitator notes for the planning and running of a series of workshops for frontline teams.

The guide is split into a number of sections represented as building blocks which go from the bottom up.

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What is the outcome?

The team(s) will have:• a greater sense of shared values, vision and purpose• a plan on how to work together more effectively• improved relationships between team members• developed a better understanding of each other’s roles and challenges

• an action plan to work on together.

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Challenges to the perfect day and module priorities

Understanding roles

Effective working relationships

Joint values and vision

Patient and user experience

Introduction to workshops

Gathering patient experience

Important factors and pre-workshop planning

‘An interesting, innovative and constructiveworkshop. Benefits are for all aspects of theservice – users, staff and managers and itencourages motivation and empowerment.

Team member


2. Important factors and pre-workshop planning

There are three key elements to assist with the integration of different teams without whichintegration fails to happen effectively.

• Clear explicit permission for teams to work together.• Time to be able to meet and discuss ways of moving forward.• A structure in place to be able to do this work. Clare Price-Dowd, NHS Institute for Innovation and Improvement 2012

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No.

1

2

3

4

5

6

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Question

Does your organisation have seniorexecutive support for this integrationwork?

Are the executive team clear on the scaleof integration required?

Are the executive team publicly committedto actively supporting this work?

Can you describe how this work fits withyour organisational plans?

Is this work a priority for the organisation?This needs to be agreed before going anyfurther.

Do you have time or a specific person tohelp facilitate this work?

Have regular briefing sessions been set upwith your executive lead?

Notes

This is essential to ensure continued momentum.

This will help you plan the extent of joint working expected.This is particularly important when working across directoratesor different organisations.

Public commitment helps maintain the priority of the work.

Making the link between local integration work andorganisational aims helps maintain impetus.

Think twice about getting teams to work together if yoususpect this may not be considered important in the comingmonths.

Preparation and running of the workshop and helping teamswork on the relevant modules will require dedicated support.

These will help keep the work on track and executive supportwill help overcome any challenges.

Yes No If NoWhat action areyou taking?

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2. Important factors and pre-workshop preparationExperience shows that certain elements need to be in place if you want to increase the chances of supporting teams in theirintegration efforts. As the service manager for the team or the facilitator for the workshop, ensure the following are in placebefore bringing teams together.


No.

8

9

10

11

12

Question

Are there clear governance arrangementsin place?

Ensure teams are willing to engage inintegration

Is there time and resource to undertakethe patient experience exercise?

Will the teams be able to engage in theworkshop?

Will the teams have the time to engage inaction plan implementation in thefollowing months?

Notes

Once commenced, the integration work needs to bemaintained. Someone needs to have the time, knowledge andresources to pull the concepts together. Over timeresponsibility should be passed to the service manager.

There needs to be clear responsibilities allocated to servicemanagers/team leaders/team members to ensure the actionplan is undertaken with partners.

There also needs to be clear agreement with the neighbouringteam/organisation on who will lead/contribute to specificactions work and how progress will be reported acrossteams/organisations.

Unless teams are prepared to work together in a proactiveway this process will fail.

This is a powerful tool which will help bring teams together inthe workshop. If doing this work is a struggle it may indicateother problems further down the line.

Teams need to have time together to develop joint values andvision, understanding and plan of work for the future.

All the time and energy invested in the workshop will only beof benefit if teams are enabled to work on the agreed actionplan in the future.

Yes No If NoWhat action areyou taking?

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Pre-workshop preparation

Complete these actions before holding your first workshop:

No.

1

2

3

4

5

6

Action

Complete checklist above

Complete ‘Gathering patient experience’ section – ensuremembers from all teams are involved in this

Consider your workshop structure

Promote joint working on an action plan across teams andwith senior managers

Clarify the high level plan for joint working over next 12months and expected outcomes

Book venues and prepare materials

Notes

Without these elements in place the joint work may prove more challenging.

Teams should commence this work at least four weeks before the workshopis held.

Decide on one full day, or a number of half days or short sessions run over aperiod of time.

Take time to internally market the workshop. Be clear on your messaging todevelop a sense of anticipation and excitement.

Emphasise empowering nature of the workshop activities.

Teams need to be aware of what is happening and what is expected ofthem.

Ensure teams have plenty of notice about dates and as many team membersas possible from each team are able to attend.

Tick whencompleted


3. Gathering patient and user experience

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3. Gathering patient and user experience

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‘The lack of joined-up care is the biggest frustration for patients, service users and carers.Conversely, achieving integrated care would be the biggest contribution the health andcare services could make to improving quality and safety. Patients, service users and carerswant continuity of care, smooth transitions between care settings, and services that areresponsive to all their needs together.’National Voices

Patients and users tell us that they value their experience of care as much as clinical effectiveness and safety. A key element inimproving the people’s experiences must be to understand what they currently feel about the service provided. You may alreadyhave existing insights (patient feedback/complaints/quality reviews/staff insights), but now is a good time to obtain fresh feedbackand experiences about the current service. Local engagement teams will be a key resource.

It is essential to consider service users experiences from all angles. If two teams want to work together then understanding how aperson feels at different points in their journey is paramount to ensuring seamless and successful care.

Involving people has a positive impact on how services are designed, planned, delivered and run. Teams need to find ways andtime to hear and act on user experience as part of their everyday activities. There are a range of engagement tools available.


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No organisation can become complacent about having the experience right for its patients and users every time. To improveunderstanding you need to gather feedback, make improvements based on that feedback, measure the improvements and sharethem as widely as possible. Services need to work together and importantly work with patients, users and families to transformtheir experiences.

Start to gather user experience information no later than four weeks before the workshop to ensure you have material availablefor use at the workshop.

You may need to get their written consent to share their views. Refer to your organisational policies for guidance on this.

Tools to useYou could use a combination of the following (examples of these can be found in the appendices to this document).a. Experience questionnaire b. Experience diaryc. Interviews with patients and users and their relative/carers. These could be videoed so they may be shared with the

integrating teams. d. Relevant information about complaints, compliments, surveys etc. that is available to you from your organisation

Gather your insights into a format that can be shared with integrating teams at the workshop.

Remember to provide feedback to patients and users who contributed to this work. You may also be able to share planned actionfollowing the workshop.

Why is getting patients’ and users’ experience important to integration?• Proves that the team value insights into patient and user experience.• Puts patients and users at the heart of the process.• Reviews current knowledge about patient and user experience.• Captures information that can be shared and discussed by both teams at the workshop.


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1. Experience Questionnaire

Preparation time: Up to 30 minutes.

What is it? A questionnaire that will help your team understand how patients and users feel at different stages of their journey.

Resources:Printer, photocopier, paper, stamps, envelopes.

What to do:Please edit the template shown below to suit your patients’ or users’ needs and experience.

1. Decide on the element of the care journey that you want to explore. Who is your target audience and what is your sample size?2. Go to the appendices section of this document and you can download the amendable tool.3. Re-write the steps to fit your patient or user group in relation to their pathway of care (the orange row in the chart on the

following page).4. The suggested words (happy, supported etc.) can be re-written if you wish and saved.5. Print off the number of copies you need. 6. Distribute the questionnaire to your staff to give to patients.7. Distribute to patients or users with a sealable stamped addressed envelope and include a letter.8. Make it clear that they can either post the questionnaire back or hand to a member of staff for collection.9. Collate the feedback from the returned forms and use to discuss at the relevant workshop.

Remember you will need to explain to patients or service users why you are doing this work and that you want to know about how theyhave felt during the period of time they were receiving treatment, care or support.

All teams who are involved in the Integration work will need to gather some form of patient and user experience so that feedback canbe discussed in the workshop. If a team is an integrated team, getting feedback from patients and users who are seen by different teammembers would be useful.

Bear in mind you will need to provide feedback to those who contributed. You may also be able to share planned action following theworkshop.

Referral

happysupportedsafegood

comfortablein painworriedlonelysad

Write yourown words

here

First Contact



Write yourown words

here

Waitingfor Visit



Write yourown words

here

First Visit



Write yourown words

here

Planning



Write yourown words

here

NegotiatingExpectations



Write yourown words

here

Treatment/intervention



Write yourown words

here

SubsequentVisits



Write yourown words

here

Discharge



Write yourown words

here


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Experience Questionnaire


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2. Experience Diary

Preparation time: Up to 30 minutes.

What is it? A diary for the patient or service user to record their thoughts about the care received and their emotional response over a set periodof time.

The diary is useful for people who may prefer writing about their experiences with more time to reflect.

Resources:Printer, photocopier, paper, stamps, envelopes.

What to do:Please edit the template shown on page 19 to suit your patient or user needs and experience.

1. Decide on the element of the care journey that you want to explore. Who is your target audience and what is your sample size?2. Go to the appendices section of this document and you can download the amendable tool.3. Edit the diary to suit the needs of your patients or users and what you want to explore. Save changes.4. Print off the number of copies you need.5. Distribute the diaries to your staff to give to patients and users.6. Distribute with a stamped addressed envelope and include a letter of explanation.7. Make it clear that they can either post the questionnaire back or hand to a member of staff for collection.8. Collate your feedback, analyse the themes and use to discuss at the Integration workshop.

Remember you will need to explain to patients and users why you are doing this work and that you want to know how they havefelt about the care they have received from your team. They can also capture their experience on the days when others have visitedor no one has provided care.

All teams who are involved in the Integration work will need to undertake some form of patient or user engagement activity so thatfeedback can be discussed in the workshop.


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Experience Diary

Dear XXX,

This diary has been designed for you to record yourthoughts about the care you have received andhow you feel about it.

Your experiences and thoughts will help us toimprove health and care services.

Once you have completed the diary please put itinto the envelope supplied. This diary will becollected after a set period of time by a member ofour team - or if you prefer you can post it back tous at the address on the envelope.

This is voluntary - there is no need to do it if youwould rather not.

If you have any concerns please talk to a memberof the team or call us using the telephone numbersupplied.

Experience Diary

Write about your experience of our services inthe spaces below.

Your ExperienceHow did it feel?

Monday

Tuesday

Wednesday

Thursday

Friday


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3. Interviews

What is it? Talking to patients, users and relatives/carers to gather information, facts, opinions and ideas about the care that they, or a lovedone, receive. Ensure these interviews are undertaken at least four weeks prior to the workshop so that the content can be analysedand prepared to share at the workshop.

Why do it?You may think you know what patients and users think and feel but until you ask them, do you really know? Asking for their thoughts and experiences will give you a different perspective.

When to use?Before you start the integration work so that you understand how patients and users feel about:• The way you currently work – ask them to consider both good and bad points.• What needs to change – ask them to discuss their suggestions.

After making changes to improve integration, use this method to understand how patients and users feel about the new way ofworking:• Is it an improvement?• Are there any issues?• Can further improvements be made?

‘Talking and listening to patients and userswill be vital to the success of your integrationwork.’


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If you are able to video your interviews, this will provide a very rich and powerful way of demonstrating to others how your patientsand users think and feel.

Video - top tips

1. Practise using the camcorder and how to hold the camera to avoid shaking and jerky movements before you record anything. Use a tripod if possible.

2. Ask staff, patients and users for written consent to video. If they are unable to give informed consent assume you do not have their permission and do not video them. Your governance or communicationsdepartment can help you with this.

3. Give staff members at least one day’s notice of the intention to video. Members of the public are likely to want more notice than this.

4. Make sure the camera is charged and that you have an empty tape/memory stick. Choose a room with good lighting and do a short test run to check all is working well.

6. Try to put staff, patients and users at ease so they feel comfortable sharing their experiences..

7. Before sharing the video with the multidisciplinary team, watch the video to make sure it has recorded properly, to resolve any technical playback problems and to begin to understand the issues presented by the video.

Watching the video back - involve allrelevant staff

Follow simple ground rules:• involve all relevant staff• observe, do not judge or comment • note everything you see• be open minded about ideas or criticism. Resist the temptation to defend yourself, this is an opportunity to see what can be improved and learn together as a team

• if limited time is available, focus on the key points of the interview..


4. Workshops

4. Worksh

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4.WorkshopsYou may want to run a full day workshop and cover allelements in one day or you could have several workshopsessions whereby two or three of the blocks are covered at atime. If the elements are covered using an incrementalapproach, build in sufficient time at the beginning of eachworkshop to create cohesion between the team members,as some of the energy from earlier workshops may havebeen lost.

If your team have covered any of these aspects in detail aspart of initial integration work, use more of the availabletime for the next element. Timings shown in the guide for allthe facilitated workshops are estimates. The “how to runthe session” guides are to help you facilitate the workshopeffectively and provide you with the information required foreach section. Do take more time for certain sections if youfeel that teams require this.

All the workshop sessions have a slide set available for youruse. Click on the link in each section of the facilitator’s guideto access this resource.

4. Worksh

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Challenges to the perfect day

Understanding roles




Introduction to the workshop


Suggestions on how to divide the workshops

4. Worksh

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Challenges to the perfect day

Understanding roles




Introduction to the workshop

Workshop 1

Workshop 2

Workshop 3


5. Introduction to theworkshop

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5. Introduction to the workshop

What this section aims to achieve

Here you need to set the context and explain to the participants what you are trying to achieve with the integrated workshops.Discuss the organisation’s position on integrated working. Explain to staff that the purpose of the workshop is:• to understand the experience of our patients and service users – and how integration could improve the experience.• to get a better understanding of each other – each person’s role and the constraints experienced by each team e.g. social care

colleagues and local political considerations,healthcare teams, financial constraints, commissioner requirements etc.• to identify where teams can jointly work together to improve integration of care.

Ensure the correct terminology is being used to suit all teams involved. Suggest participants may stop you at any point if they areunclear about the language or any jargon being used.

For each section of the workshop a slide set can be found by following the specific link in the facilitator’s notes.

How to run the session

This session is to be used as the introduction to the work your teams are embarking on.

You may wish to set ground rules for the workshop, see example on page 28.

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Section

Welcomeand runthrough theagenda

Introductionand contextsetting

Introductionsto each other

Steps

Explain what is goingto happen in thesession and the needto stick to the timesgiven.

Setting the context.

Time

10 minutes

15 minutes

15 minutes

Facilitator input

Welcome to the workshop.Be clear about purpose of the workshop.Run through the agenda for the day.Set ground rules to be used through theworkshop.

Discuss with the participants what terminologyeveryone is comfortable using. Is it patient, client,service user? Establish this at the beginning toprevent negativity in the room.

Ensure terminology used is understood by allparticipants.

Set the scene of where local organisations arewith integration and patient and userinvolvement.

Explain the importance of more integrated care tothe organisation(s).

Describe how this workshop and joint work linksto:i. strategic goals, ii. organisational concernsiii. organisational commitmentiv. improved patient and user involvementv. local context.

Describe the organisational commitment behindthis work.

Introduction exercise/ice breaker.

Resources

Projector, Laptop,Flipchart paper, Pens, Sticky notes, Sticky tac.

Notes

Ensure you havenational and localcontext aboutintegration. Havinglinks to strategic goalsand aspirations willalso help with contextsetting.

Having a seniormember of staffpresent from one orboth organisationswho can support thedelivery of thesemessages is verybeneficial.

Find an ice breaker which

suits your teams. This is

particularly important if

team members do not

know each other well.


Example of Ground Rules that may be used for the workshop:

• everyone has a valuable contribution to make, respect their views • there are no stupid questions!• do not interrupt/speak over people • be open and honest• no blame or criticism• respect confidentiality• think creatively/generate ideas.

Discuss with participants if these are acceptable and if anything else should be added.

Additional information

Use this session to ensure everybody is on board with the broad aims of this work and has had the opportunity to discuss thereasons for undertaking it.

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6. Patient and userexperience‘It is really important to get the patient and users’experience information and use it to focus onpatients throughout the workshop.’Victoria Bagshaw, Deputy Director of Nursing, Doncaster & Bassetlaw Hospitals NHS Foundation Trust

6. Patient an

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6. Patients’ and service users’ experience


It is crucial that the patients’, users’, relatives’ and carers’ views are understood when integrating teams. If teams understand theimpact of poorly integrated care, they will be more motivated to work together.


Get each team to feed back what they have learnt from the patient and user experience work. Give each team the opportunity totalk about their findings.

Encourage the whole group to discuss the findings and think of ways that experience may be improved.

Ensure that the teams come up with a list of areas for improving experience. This will be helpful later when deciding on an actionplan.

6. Patient an

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Section

Patient anduserexperience

Steps

Get each team to feedback the results of their patient anduser perspective work.

Discuss ways ofimproving care using a more integratedapproach.

What areas can teamsimprove upon?

Time

60 minutesfor wholesession.

30 minutes(15 minutesper team).

15 minutes.

15 minutes.

Facilitator input

Each team to describe how it feels for a patientor user to be cared for by the team. Includeboth good and poor examples.

Share any insights they have about thecompliments and types of complaints received.

Given these experiences what areas of careneed to be improved? Discuss in some detail theexamples provided.

What is currently missing?

Encourage discussion about why a moreintegrated joined up care approach would bepreferable.

Capture a list of areas where improvements canbe made.

Resources

Flipchart and pens

Patient and userExperience

Pre-prepared teampresentations. This canbe PowerPoint /flipchart/pictures etc.

Notes

Pre-work must becompleted and arelevant presentationprepared to make thisworkshop successful.



This session will not work without the preparation as suggested in part three of the document “Gathering patient and userexperience.” If more than two teams are involved there may be a need to adjust timings.

Consider whether the teams already have any additional information about their patient or user views which could be used in thisexercise. Do the organisations have any existing patient or user experience information that may be of value to the team?

6. Patient an

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See the slide set


7. Joint values and vision

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7. Joint values and vision


To enable teams to discuss their values and consider from an emotional view, how they connect with patients, users andcolleagues. You will need to consider organisational values and remember, if you are engaging with a team from anotherorganisation have their values to hand as well.

What are values?

Values underpin the quality of service we deliver to patients, users and communities. Compassion, dignity and respect are at theheart of a good patient experience. We need to do more to highlight and celebrate these values. Values can also help us to build aculture in which safety is paramount and everyone pulls together to deliver seamless care. Safety, effectiveness, experience: valuesare the bedrock of quality.


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Where to begin?

What motivates your staff to give their all each day at work? What inspired them to train for years? What guides them when theyface difficult professional decisions and gives them a sense of satisfaction in a job well done?

What to do once you have established your team values

Use the values to help the team create their team vision. The shared vision should reflect the aspirations of all those involved in theworkshop.

What is a vision?

A vision is a compelling statement that tells everyone your ambition for your team. Visions are about feelings, beliefs, emotions, and pictures. It defines the future you want to create.

Why create one?

An exciting team vision can galvanise your team and so improve your integration process. It also enables others to understand your aspirations.


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Where to begin?

This session should be about creating a joint, energising vision and not an opportunity for staff to be negative. Although somestaff may not see the need to do this, try to convince them of the importance of this session.

Encourage everyone involved to think about what they would like the vision to be.

Use the values which are agreed to help shape the vision. Would the team prefer it to be more pictorial?

Think about creating a short sentence or two from the words agreed by the team. Test to see if everyone feels the statementcreated reflects what they are trying to do as an integrated team.

If, after the workshop you feel the vision is not truly reflective of your integrated team aspirations, keep working on it until all theteam(s) are happy and comfortable with the vision created.

What to do once you have created your vision?

Display the vision in a prominent place in your team base(s).

Use it to help you choose what to improve first when the team are unsure of their priorities.

Vision is the joint focal point and a cornerstone for your integration efforts.


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Section

Joint Values

Steps

Explain what we meanby values.

Get small groups tothink about theirvalues and what thismeans to them.

Feedback to wholegroup.

Time

40 minutes intotal.

5 minutes.

15 minutes.

20 minutes.

Facilitator input

Give examples of social care or NHSorganisational values and the organisation’svalues.

In mixed groups, ask participants to share anddiscuss their values. Ask them to capturethoughts on flip chart.

Pin up flipcharts on the wall. Each group sharestheir list of values with the whole team.

Decide on which values everyone agrees upon.

Capture ideas from group on flip chart.

Resources

Flipchart and pens.Sticky notes.

See the slide set Jointvalues and vision.

Flip chart and pens.

Notes

This is designed to bean enjoyable exercisewhere teams create ajoint picture of howthey would like theirintegrated teams towork.

Sharing these valueswill help participantsunderstand the sortsof things values cover.

How to run the session continued

Section

Joint Vision

Steps

Explain why we need avision.

Discuss as a wholegroup examples andthoughts about visionstatements.

In small mixed groupscreate a draft vision.

Feedback.

Whole group.

Time

40 minutes intotal.

5 minutes.

15 minutes.

10 minutes.

10 minutes.

Facilitator input

Create joint vision

You and your team need to picture and describeyour preferred future as vividly as possible.

Values are about guiding principles about whatyou think are important. The vision is astatement of how this integrated service willlook and feel to the patient and to others.

Ensure all the team have an equal say in thedevelopment of their vision.

Think of the values you have agreed upon, arethese some of the words that you may like tohave in your vision? Would you prefer it to bemore pictorial?

Capture your vision on a flipchart. This may be acombination of words and pictures.

Get teams to feedback to whole group.

Agree upon a vision. Facilitator to capture onflipchart.

Resources



Notes

The group may decideto base the overallvision on somethingone of the groupsproduced, or it maybe a combination ofwords and pictures.This is likely to needworking up after thesession. Ensuresomeone is identifiedto complete this –ideally one of theparticipants willvolunteer.


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Section

Joint Vision

Steps

After the workshop

Time Facilitator input

If the whole team is not present, you need toensure the rest of the team has a chance tocontribute at a later date.

Ensure teams follow up and complete theirvision after the workshop. Agree timeframes forcompletion of vision statement.

Resources Notes



The vision could be a written statement or be represented in the form of a picture. A good vision:• sets a standard of excellence• clarifies purpose• inspires enthusiasm• is easy to understand by others• is ambitious.


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8. Effective working relationships

8. Effective workin

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8. Effective working relationships


We know that good working relationships are essential in generating energy and ideas for improvements. This section of theworkshop is about getting teams to consider how well they work together. Do they have good working relationships? Are thereareas which could be improved upon?

If relationships are poor between the teams, acknowledging this at the start can help to make things better. If the relationship isalready good, the teams can decide what will make it even better.

We want to ensure that interactions between team members generate energy and innovative ideas to improve care.

8. Effective workin

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‘[Patients and service users] want organisations not to argue betweenthemselves or send conflicting messages. They expect professionals towork together as a team around the patient, and they want services towork together likewise: that is, to come together at the point they areneeded, and to meet people’s needs in the round.’National Voices


Much has been written about relationships in organisations and what makes them a success. Four key factors are frequentlyreferred to as key to helping change. They are as follows.

8. Effective workin

g relatio

nships

Collaborative action

Common goalsand values

Deepunderstanding

Mutual respectCollaborative actionwhere team memberswork and learn together

Common goals and valuesthat go beyond our differences

Mutual respect for each other’s unique role,potential for contribution

and expertise

Deep understandingof each other, this happens

by active conversation

Section

EffectiveWorkingRelationships

Steps

Introduction - Discussgeneral concept ofeffective workingrelationships.

Completequestionnaire.

Time


5 minutes.

10 minutes.

Facilitator input

Show slides and discuss comment by DavidNicholson about integrated working.

Photocopy the “Effective WorkingRelationships” questionnaire and have a copyfor each participant.

Ask each person to individually rate how theythink the relationship is with other teammembers (or if more than one team, with thatsecond team).

Each person should give one rating for each ofthe four areas.

Resources

See the slide setEffective workingrelationships.

Copies of “EffectiveWorking Relationships”questionnaire –one perperson.

Notes

Be aware of anyconflict which maydevelop during thisdiscussion.

This is not aboutjudging one anotherbut trying tounderstand the gapsso that teams canwork on improvingthe integrating team’srelationships.


8. Effective workin

g relatio

nships


After introducing the topic each person will use the questionnaire supplied (see page 48) to individually rate the workingrelationship between the teams. These ratings are put on a flip chart to show the range of perceptions. The teams then discuss thefindings and identify actions that can improve the relationship.

Section

EffectiveWorkingRelationships

Steps

Dot marking (seeexample on page 49).

Group discussion.

In four groups.

Feedback and actionplanning.

Time

5 minutes.

5 minutes.

20 minutes.

20 minutes.

Facilitator input

Get all participants to come up to the flipchartand mark on the pre-prepared chart how theyhave voted.

Everyone can have same colour pen or you maywant to give different colour pens to thedifferent professional groups to gain additionalinsight.

See example (on page 49) of how to write upflipchart so that individuals can mark on their dots.

Discuss what the dot marking shows you.

Split into four mixed groups with each grouptaking one of the following sections:-• mutual respect• deep understanding• collaborative action • common goals and values.

Each group to identify and capture actions ofhow to improve the current state of the teamdynamics. To be captured on the actionplanning sheet.

Come back together and each small group feedback where they are now (current state) andwhere they want to get to (desired state) andproposed actions – see example on page 50.

As a whole group discuss the points made andadd to actions if required.

By the end of this session actions should beidentified on how to improve the situation inthe future.

Ensure specific names and dates have beenassigned to each action.

Resources

Flipchart and pens.

Flipchart paper for eachgroup.

Notes

If the board is turnedaway from the groupit allows a moreconfidential methodof feedback andshould mean staff arehonest about howthey really feel.

It is helpful if groupscan move into breakout areas.

See heading exampleon page 50.


8. Effective workin

g relatio

nships



8. Effective workin

g relatio

nships

Effective Working Relationship questionnaireA copy is available in Appendix 3 to photocopy

You want to work more effectively and closely with colleagues – this could be within your team or across the integrating teams.Think about these statements and decide which one applies to how you currently work. Please complete this form individually.

Mutual respect1One or both teams put downthe role, contribution orexpertise of the other.

Deep Understanding1One or both teams feels thattaking time to developunderstanding of the other isa waste of time.

Collaborative action1One or both teams activelyavoid working together withthe other party and seems todisrupt any such efforts.

Goals and values1One or both teams activelyhave goals or values that arenot acceptable to the otherparty, or they belittle the goalsand values of others.

2One or both teams feels thatactively demonstrating respectfor the other is not reallyimportant.

2Neither team feels that havingan understanding of eachother’s points of view andsituation is essential forgetting the work done.

2Neither team feels thatworking together is really allthat important (“you do yourbit and we’ll do ours”).

2Neither team feels thatagreeing some common goalsand values is really necessaryin getting the work done.

3One team feels it has respectfor the role and contributionor expertise of the other butdoes not believe the feeling ismutual (“junior partner”).

3One or both teams feels thatdeveloping a betterunderstanding of the otherspoint of view and situationwould be helpful but there islittle time to do this.

3One or both teams feels thatworking together would behelpful; but there is little timefor this or when joint effortsare set up the work ends upbeing done separately.

3One or both teams feels thatagreeing some common goalsand values would be helpful,but there is little time for thisor the teams know they havedifferences of opinions andthey don’t want to deal withthem.

4Both teams have a respect forthe role and contribution orexpertise of the other but thisis not actively communicatedin words or behaviour

4Both teams have someunderstanding of the other’spoint of view and situationthat is the result of gooddialogue, but more is needed.

4Both teams feel that workingtogether is important andthey do it sometimes, butmore is needed.

4Both teams have agreed somecommon goals and values butthese are not always activelyused in helping change ordecision making. (“often justwords on paper”).

5Both teams have a highdegree of respect for the roleand contribution or expertiseof the other and this iscommunicated in words orbehaviours.

5Both teams have a deepunderstanding of each other’spoint of view and situationthat is the result of ongoingdialogue where both partiesactively listen.

5Both teams feel that workingtogether is very important andthey take every opportunity todo so.

5Both teams feel that agreeingsome common goals andvalues is very important, andthey actively use these inshaping change, makingdecisions, resolving conflictetc.

From ‘Pattern Mapping’ – Plesk, Bibby and Garrett


8. Effective workin

g relatio

nships

Example of dot marking on the flipchart

Section

Mutual respect

Deep understanding

Collaborative action

Common goals and values

1 2 3 4 5

!

!!!

!

!

!!!

!

!

!!!

!


8. Effective workin

g relatio

nships

Example of discussion of current and desired state and actions going forward

Planning Sheet

Current state

We don’t allocate enough time forreally understanding each otherand truly working together onthings.

Many of our joint projects are co-ordinating our largely separateactions.

Desired state

True collaborative action andmutual respect between teams.

Common goals and values areopenly discussed and regularlyupdated and changed and activelyused in day to day decisionmaking.

Actions

Introduce shadowing of staff tounderstand each other’s role.

Identify and promote commongoals.

Share patient and user perspectiveat the beginning of team meetings.

By whom

SH to organisefor team

SM

By when

July 2014

Sept 2014


Further information can be found about this topic from: - Plesk, P. and Garrett, S. (2003) Mapping Behavioural Patterns, Exploring the underlying factors that accelerate or impede system transformation.


9. Understanding roles

! !

9. Understan

ding ro

les


9. Understanding rolesHow much do we understand about each other’s role?


In order to effectively develop your integrated team it is important that all team members have a clear understanding of thediffering roles within the integrated team and any myths are dispelled. If this work is being done in a uni-disciplinary teamconsideration of the roles of the differing grades of staff may be of value.

Failure to understand each other’s roles and responsibilities can create tension, miscommunication and inefficiency within the team.


In this session participants talk about their roles and their understanding of the role of others. This helps everyone dispel any mythsthey may have.

Depending on how many people are attending the workshop, group into specific disciplines. In order to do this effectively you willneed to have more than one person of each discipline. Where this is not possible, mix similar roles together. Ideally groups of threeor more will work best. Organise the groupings before you explain the task to the participants.

Get each discipline to talk about the role of one other discipline in the team. (E.g. Group A talk about Group B. Group B talk aboutGroup C. Group C talk about Group A). Once Group A have shared their understanding of Group B, then Group B can clarify anymisunderstandings and share deeper insights into their role and constraints.

What myths can be dispelled? Were there any surprises? Discuss these points in the whole group. This exercise has proved to befun and enlightening.

9. Understan

ding ro

les


Section

UnderstandingRoles

Steps

Introduction.

Split into singleprofessional groups.

Time

60 minutes -dependingon number ofdifferentdisciplines inteam(s).

5 minutes.

25 minutes.

Facilitator input

Plan the way this is going to work acrossdisciplines beforehand, so it is organised whenyou tell the participants what they are going todo.

Introduce the exercise to the group.

Organise so specific disciplines sit together forthis exercise.

If there are less than two representatives of aspecific discipline, group with others who dosimilar roles if possible.

On flipchart paper each group writes what theythink each different service group does.

For example if you have a group of communitynurses/physiotherapists/social workers, instructthe community nurse to describe the role of asocial worker, the physiotherapists to describethe role of the community nurses and the socialworkers to describe the role of thephysiotherapists.

Ask each group to answer these questions:- • What patient/client groups are cared for by this discipline?

• What are the key activities undertaken by them?

• Where do their referrals come from?• What are their biggest constraints/challenges?

The aim is to find out what understanding thereis of the roles of the different professionalgroups.

Resources

Flipchart paper andpens.

Notes

Be aware ofcontroversy and keepteam members ontrack.

Try to make this fun.Reinforce this is anopportunity to dispelunhelpful myths.

9. Understan

ding ro

les


9. Understan

ding ro

les

Section

UnderstandingRoles

Steps

Feedback to the wholegroup.

Clarification of actualroles.

Group discussion.

After the workshop.

Time

25 minutes.

5 minutes.

Facilitator input

In turn, each group feeds back the answers tothe above questions focusing on the groupallocated to them. Get them to refer to their flipchart.

The service group described then has anopportunity to confirm, challenge or clarify theviews expressed. They can dispel any myths andgive actual examples of what they do.

Discuss if anyone is surprised by what has beenrevealed. What has everyone learnt from thatexercise?

Some teams have found it of value to write ashort description of each service role to sharewith the whole team for future reference.

Resources

Add the additionalpoints identified to theflipchart paper in adifferent colour tohighlight points notconsidered.

Notes

Depending onamount of groups,think about the timeyou have forfeedback.

Time allowing,encourage thenominated teams toprovide deeperinsights into theirroles and work.

Everyone is involvedin the feedback to thegroup so all can hearwhat is beingdiscussed.

Move on to secondgroup and repeat.


Greater understanding of each other’s roles and constraints is an important platform in building a more integrated team. This exerciseencourages a discussion about roles and constraints. It can help dispel myths and develop deeper insights as well as reinforce goodlevels of mutual understanding. (Some teams may use this as an opportunity to organising shadowing visits).



10. Challenges to the perfect day‘A very exciting day. A room full of positivity at the end of the day.’Staff nurse attending the workshop

10. Challen

ges to

the p

erfect day an

d m

odule p

riorities

Section

Challengesto theperfect day.

Steps

Introduce the session.

Time


5 minutes.

Facilitator input Resources

See the slide setChallenges to theperfect day.

Notes

10. Challenges to the perfect day and module priorities


Here the teams identify key areas where they can work together to improve integration. They create an action plan which they willimplement jointly.



10. Challen

ges to

the p

erfect day an

d m

odule p

riorities

Section

Challengesto theperfect day

Steps

Individually

Feedback to wholegroup

In small groups

Time

10 minutes

20 minutes

10 minutes

Facilitator input

Individually consider what day to day challengesare experienced while you are at work. Writeone challenge per sticky note.

Each person reads out one of their challenges in turn. They are added to the flipchart by thefacilitator. This way the facilitator can ensureissues are appropriately matched to specificmodules.

For example, the facilitator can try to groupsimilar challenges together: • “I can never find the information I need to do my job easily.” Patient user status.

• “Referrals are terrible.”• Communication between teams.• “Cupboards are always a mess” - Workplaceorganisation.

Keep going around until people have nothingnew to add.

Each group completes this statement….

“To improve the integration of care for ourpatients, we should work jointly on…..”

Ask them to list the top five modules (or allmodules) and the reasons why they areimportant to address the day to day challenges.

Resources

Sticky notes

Flipchart paper

Flipchart and pens

Notes

If there are severaldifferent disciplines/services considerusing specific coloursfor each one.

The facilitator maywant to identify somecategories in advanceto help withgroupings.

10. Challen

ges to

the p

erfect day an

d m

odule p

riorities



Section

Challengesto theperfect dayand modulepriorities

Steps

Feedback

Agree high levelactions

Time

15 minutes

30 minutes

Facilitator input

Each group feed back their choice of 5 key areasand rationale. The facilitator notes the keyareas and a brief note made of the reasons whythis will help with integration and the day to daychallenges.

Discuss which of the key areas to work on anddecide upon the priority order based ondiscussion with the whole group.

Now create a high level action plan for jointworking – which areas do we want to work ontogether first? Who is going to be responsiblefor what?

How is this going to be achieved and what arethe time scales involved?

This will require more detailed planning after theworkshop, but ensure that teams leave theworkshop with a clearly defined high levelaction plan to take this work forward.

Resources

Flip chart prepared withheadings:

Key areas and rationale

Notes

You may want to teaseout which challengescan be addressedwithin one team andwhich require jointworking across teams.(e.g. organising yourwork teams modulecan be implementedby individual teams toimprove their ownworking environment.However, if it is ashared area it shouldbe implementedjointly).

Ask for a volunteer tolead and a buddy foreach of the key areas.Get people fromdifferent teams to linkup for specific areas.

10. Challen

ges to

the p

erfect day an

d m

odule p

riorities




10. Challen

ges to

the p

erfect day an

d m

odule p

riorities


Once teams have decided upon the key areas for action they wish to work on it is important to ensure that momentum from theworkshop is kept up. The best way of doing this is for teams to create an action plan of implementation with staff volunteering totake the lead.

There may be particular organisational priorities or resources that will help them make more progress on particular areas.

Example of priority order of modules based on team discussion

The sheet below is an example of a high level action plan.


Module

Workforceorganisation

Knowing how weare doing

Patient user status

Votes

4444

44444

444

44444

44444

Rationale

Lots of time lost looking for items. However we can address thisin our own team spaces.

It would be helpful if we had shared indicators so we were awareof how our joint efforts were supporting our shared patients.

We are often unclear about the status of patients and what theother team has or hasn’t done.

Priority for joint working

Low

Medium

High

Who will lead andbuddy each module

AB and YB

SM and SH

10. Challen

ges to

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erfect day an

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odule p

riorities


11. What happens next?‘An inspiring and enjoyable workshop givinghope for the future.’Team Leader attending workshop

11. What h

appen

s next?


11. What happens next?

After holding this workshop it is important that the actions discussed and agreed upon are implemented.

The workshop facilitator and service manager(s) together with the team leader(s) need to meet to discuss the actions and timeframes in which the work is to be done.

A detailed action plan should be devised which also includes information about the impact of the work so that success can bemeasured. Measuring the impact of what teams achieve is key to the success of this Integration work.

Teams may need extra support to take action when working across two teams. They should always be mindful of the need tointegrate the care they provide wherever possible.

Regular meetings to ensure the operational success of the action plan will ensure that any difficulties are overcome and the planstays within the time frame set.

It is also important to remember the important factors that will make this a success, including leadership engagement, governance,measurement and resources.

11. What h

appen

s next?

‘This has broader applications, not just for integrating teams; it is an enabler for all productive teams.’Steve Williamson, Senior Nurse, Nottinghamshire Healthcare NHS Trust


12. Appendices

12. Appen

dices

Referral



Write yourown words

here

First Contact



Write yourown words

here

Waitingfor Visit



Write yourown words

here

First Visit



Write yourown words

here

Planning



Write yourown words

here

NegotiatingExpectations



Write yourown words

here

Treatment



Write yourown words

here

SubsequentVisits



Write yourown words

here

Discharge



Write yourown words

here


12. Appen

dices

Appendix 1 - Experience Questionnaire


Experience Diary

Dear XXX,

This diary has been designed for you to recordyour thoughts about the care you have receivedand how you feel about it.

Your experiences and thoughts will help us toimprove health and care services.

Once you have completed the diary please put itinto the envelope supplied. This diary will becollected after a set period of time by a memberof our team - or if you prefer you can post it backto us at the address on the envelope.

This is voluntary - there is no need to do it if youwould rather not.

If you have any concerns please talk to a memberof the team or call us using the telephonenumber supplied.

12. Appen

dices

Appendix 2


Experience Diary

Write about your experience of our services inthe spaces below.

Your ExperienceHow did it feel?

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Sunday

12. Appen

dices


12. Appen

dices

Appendix 3

Effective Working Relationships – QuestionnaireYou want to work more effectively and closely with colleagues – this could be within your team or across the integrating teams.Think about these statements and decide which one applies to how you currently work. Please complete this form individually.

Mutual respect1One or both teams put downthe role, contribution orexpertise of the other.

Deep Understanding1One or both teams feels thattaking time to developunderstanding of the other isa waste of time.

Collaborative action1One or both teams activelyavoid working together withthe other party and seems todisrupt any such efforts.

Goals and values1One or both teams activelyhave goals or values that arenot acceptable to the otherparty, or they belittle the goalsand values of others.

2One or both teams feels thatactively demonstrating respectfor the other is not reallyimportant.

2Neither team feels that havingan understanding of eachother’s points of view andsituation is essential forgetting the work done.

2Neither team feels thatworking together is really allthat important (“you do yourbit and we’ll do ours”).

2Neither team feels thatagreeing some common goalsand values is really necessaryin getting the work done.

3One team feels it has respectfor the role and contributionor expertise of the other butdoes not believe the feeling ismutual (“junior partner”).

3One or both teams feels thatdeveloping a betterunderstanding of the otherspoint of view and situationwould be helpful but there islittle time to do this.

3One or both teams feels thatworking together would behelpful; but there is little timefor this or when joint effortsare set up the work ends upbeing done separately.

3One or both teams feels thatagreeing some common goalsand values would be helpful,but there is little time for thisor the teams know they havedifferences of opinions andthey don’t want to deal withthem.

4Both teams have a respect forthe role and contribution orexpertise of the other but thisis not actively communicatedin words or behaviour.

4Both teams have someunderstanding of the other’spoint of view and situationthat is the result of gooddialogue, but more is needed.

4Both teams feel that workingtogether is important andthey do it sometimes, butmore is needed.

4Both teams have agreed somecommon goals and values butthese are not always activelyused in helping change ordecision making. (“often justwords on paper”).

5Both teams have a highdegree of respect for the roleand contribution or expertiseof the other and this iscommunicated in words orbehaviours.

5Both teams have a deepunderstanding of each other’spoint of view and situationthat is the result of ongoingdialogue where both partiesactively listen.

5Both teams feel that workingtogether is very important andthey take every opportunity todo so.

5Both teams feel that agreeingsome common goals andvalues is very important, andthey actively use these inshaping change, makingdecisions, resolving conflictetc.

From ‘Pattern Mapping’ – Plesk, Bibby and Garrett


13. Literature and links

13. Literature an

d lin

ks

13. Literature and links

Useful literature

Care Quality Commission (2011). The State of Health Care and Adult Social Care in England: An overview of key themes in care2010/11. London: The Stationery Office.

Chris Ham, Judith Smith and Elizabeth Eastmure, (2011) Commissioning integrated care in a liberated NHS Nuffield Trust.

Department of Health (2011). The Operating Framework for the NHS in England 2012/13. London: The Stationery Office.

Ham C, Smith J (2010). Removing Policy Barriers to Integrated Care in England. London: Nuffield Trust.

Humphries, R. and Curry, N. (March 2011) Integrating health and social care Where next? London: The Kings FundIntegration (2011) Health Service Journal.

Isles Valerie (2006) cites Batten, J. (1991) Tough Minded Leadership (New York: Amacom).

Lewis R, Rosen R, Goodwin N, Dixon J (2010). Where Next for Integrated Care Organisations in the English NHS. London: NuffieldTrust and The King’s Fund.

Living our Local Values - The value of values (2009) NHS Institute for Innovation and Improvement.

National Voices (2011). Principles for Integrated Care. October 2011.

Plesk, P. And Garrett, S. (2003) Mapping Behavioural Patterns, Exploring the underlying factors that accelerate or impede systemtransformation.


13. Literature an

d lin

ks

Useful links

The following are links to other helpful materials and resources.

Principles for workforce integrationwww.skillsforcare.org.uk/POWI

Workforce capacity planningwww.skillsforcare.org.uk/Standards/Care-Act/Workforce-capacity-planning/Workforce-capacity-planning.aspx

Workforce transformationwww.skillsforhealth.org.uk/workforce-transformation

Collaborative working in social carewww.scie.org.uk/publications/guides/guide34

www.scie.org.uk/publications/integratedworking/tool/index.aspx

A Question of BehavioursWhy delivering care integration and managing acute demand depends as much on changing behaviour as new systems andstructures. Khaldi, A. www.impower.co.uk/insights/a-question-of-behaviours

Integrated care: making it happenwww.kingsfund.org.uk/projects/integrated-care-making-it-happen


13. Literature an

d lin

ks


14. Acknowledgements

14. Ackn

owled

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14. Acknowledgements

The Building Collaborative Teams workshop guide* was developed and produced with the help of many health and social carestakeholders. We would like to thank them all for their enthusiasm and passion for improving care. They all brought valuableperspectives and expertise to the development of this Guide.

We would particularly like to thank those people and teams from the following organisations for their input.

Sean Manning, Programme LeadSue Hill, AssociateDoncaster & Bassetlaw Hospitals NHS Foundation TrustDudley Group NHS Foundation TrustHealthcare Improvement ScotlandLocala Community Partnerships CICNottinghamshire Healthcare NHS TrustPennine Care NHS Foundation TrustSt. George's Healthcare NHS TrustTrafford Provider Services

*This guide was originally developed under the title ‘Productive Integration Workshop Guide’.


14. Ackn

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@NHSIQwww.nhsiq.nhs.ukTo find out more about NHS Improving Quality:

[email protected]

Improving health outcomes across England by providing improvement and change expertise

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